Exam 3: Respiratory Flashcards
What is Fi02?
Percentage of oxygen in the air that is available to the client
What is the first sign of hypoxia?
neurological deficits like altered mental status, restlessness, confusion, or anxiety
What are the signs and symptoms of hypoxia?
Restlessness
Decreased LOC
Dizziness
Behavioral changes
Fatigue
Agitation
Tachycardia
Cyanosis – Not a reliable indicator
Why is cyanosis not a reliable indicator of hypoxia?
can be difficult in darker skinned clients
How do we assess for cyanosis is darker skinned clients?
Central Cyanosis in the tongue and conjunctiva. The bluish appearance of either is a more reliable indicator of hypoxia.
What are signs that your client has an airway obstruction?
Not talking, stridor, unconscious (tongue)
What are some common airway obstructions?
Tongue
FBO
Vomit, secretions, mucus
Toys, nails, cereal
How is a foreign body removed from the airway?
CPR, Heimlich, backblows
What are interventions to address airway issues?
suctioning, pulmonary hygiene, artificial airway, intubation, trach
What are indications for suctioning?
when patients are unable to clear respiratory secretions from the airways by coughing or other less invasive procedures
What is the purpose of pulmonary hygiene/toilet?
the action of mobilizing respiratory secretions for removal
What is the benefit of hydration in pulmonary hygiene?
Adequate hydration helps to maintain the ability to clear secretions by liquifying the sputum making it thin and easily removable with minimal coughing
How would you hydrate a client who is NPO?
IV hydration
What are the dangers of retained mucus?
Increases WOB
Traps bacteria allowing them to colonize
Leads to excessive coughing
Can lead to formation of mucus plugs which hinder gas exchange
What is the purpose of incentive spirometry?
encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume
prevent atelectasis
What is atelectasis?
condition that prevents the alveoli from expanding causeing portions of the lungs to collapse and is a complication when recovering from surgery
What are the benefits of ambulation in pulmonary hygiene?
increase the general strength of the client as well as increase lung expansion. This expansion shifts mucus to the larger airways and is easier to expectorate.
Which clients are candidates for early ambulation?
Critically ill clients can be placed into early ambulation programs with assistance from respiratory therapy and physical therapy
When is an artificial airway indicated?
Anytime you use BVM
decreased level of consciousness or airway obstruction
What are indications and contraindications for an oropharyngeal and nasopharyngeal airway?
OPA
Displaces tongue
Unconscious - cannot have a gag reflex
NPA
Patient can be conscious
Cannot suspect a facial fracture
What is the nurse’s role in endotracheal intubation?
Call provider to update on status and potential need for further respiratory intervention
Inform and educate patient and family – this is a major event in the care of the patient and family should be notified
Confirm that the patient and/or family wants further intervention
Gather supplies for intubation procedure
Notify respiratory therapist for mechanical ventilator to be brought to room
What is the most common complication of a tracheostomy tube?
partial or total airway obstruction caused by buildup of respiratory secretions
What are safety precautions that we take with tracheostomy clients?
Always know the size of your clients trach –
Always have a new trach usually a size below your patients current trach at the bedside for emergencies – if the trach comes out you can place the smaller trach in the stoma to provide ventilation an oxygenation
How is oxygen administered to a client with a tracheostomy?
Oxygen delivery for trach is via a trach collar which is a specific device designed to fit over the trach
Oxygen delivery is through a humidification cylinder and communicated and regulated as FiO2 % as opposed to Liters of oxygen
Example: 40% TC (trach collar) as opposed to 6 L NC (nasal cannula)
What are the signs that a client requires suctioning?
Coughing
Mucus in the tube
Alarms
Patient request
Describe the process of using in-line suction on a client?
Suction catheter is advanced into the endotracheal tube. Suction is engaged by pressing a button on the end of the catheter. Suction is engaged intermittently as the nurse slowly retracts the catheter out of the ET tube. 1 to 3 passes may be necessary to clear all the secretions. Never suction more than 10 seconds. Allow your client to rest between suction procedures.
Why is VAP a concern?
because the ET tube gives harmful bacteria a pathway to bypass all of the anatomical defenses in the upper airway and go directly to the client’s lungs
leading cause of death in HAIs -> pts are already critically ill to need vent
What are components of a VAP bundle?
Elevate HOB to at least 30 degrees
Daily Sedation Vacations and weaning assessment
Daily Oral Care
Delirium Monitoring
Early Mobilization
PUD prophylaxis – Doesn’t directly prevent VAP
DVT prophylaxis – Doesn’t’ directly prevent VAP
What are the head of bed degrees for the different Fowler’s positions?
30° for semi-Fowler’s
45° to 60° for Fowler’s
90° for high Fowler’s
Which Head of bed position is recommended for clients with difficulty breathing?
High Fowlers
How do we know that a client requires supplemental oxygen?
assessment data - SpO2, WOB, dyspnea
Why is an airway assessment important prior to providing supplemental oxygen?
b/c blocked airway needs to be cleared first
How do we know what adjunct to use and how many liters to place on the client?
Follow the O2 protocol but use lowest amount necessary for shortest period of time (2L NC)
Indicators of effectiveness: color, LOC, HT, WOB, ABGs, SPO2
What should we do if our client has a sudden increase in their supplemental oxygen requirement?
Call RRT and increase per protocol
What is the Fi02 delivered by a nasal cannula and a nonrebreather mask?
NC = 22-44%
NRB = 90-100%
What flow rate should you use when applying a nonrebreather mask?
15LPM
What are indications that your client requires bag valve mask ventilations?
clients breathing less than ten times a minute with shallow respirations. It is also used to provide oxygen to the lower airways prior to suctioning or endotracheal intubation.
How are in hospital cardiac arrests avoidable?
There are often clear physiological warning signs that begin appearing several hours before an arrest situation – cardiac or respiratory
need early interventions at first sign of decline - trend vitals
What should you do if you notice a deterioration in vital signs?
Go up the chain, start with other nurse -> provider -> RRT
What are the criteria for activating the rapid response team?
Heartrate over 140 or less than 40
Respiratory rate over 28 or less than 8
Systolic blood pressure greater than 180 or less than 90
Oxygen saturation less than 90% despite supplementation – or a significant increase in oxygen demands
Acute change in mental status
Urine output less than 50mL over 4 hours
Nurse, staff member, family or patient have a significant concern about the patient condition
Additional criteria may include: chest pain, threatened loss of airway, seizures, stroke, or sepsis.
What decisions does the Rapid Response team make?
Whether the pt can stay on that floor with further interventions or if they need a higher level of care
Who may be included on a code team?
Charge RN – Usually ICU Charge nurse
Respiratory Therapist
MD(s): anesthesiologist, pulmonary MD, critical care MD
ICU or unit nurses
CPR Compressors
What should you do if your client is unresponsive?
Sternal rub, check pulse/breathing
When do you push a code blue button?
Unresponsive w/ no pulse and not breathing
Describe the various roles of the code team members.
Team Leader
Airway
Recorder
Compressors – CPR
Monitor
IV/Medications
What is closed loop communication?
Repeat order to confirm heard/understand
Confirm order has been carried out/completed
Helps to reduce/eliminate errors
Concise and clear language -> Calm, controlled, confident
